Right Patient, Right Product, Right Time: A Smarter Approach to CTP Use

Advanced wound imaging technologies—including near-infrared spectroscopy, thermography, and fluorescence imaging—are transforming how clinicians select and time cellular tissue product (CTP) applications. By identifying tissue hypoxia, occult infection, and perfusion deficits at the point of care, this thought leader shares how he feels providers can improve outcomes, reduce waste, and ensure the right patient receives the right product at the right time.

·      CTP success depends on timing, patient selection, and biological readiness, not one-size-fits-all application. 

·      Diagnostic imaging technologies can enable real-time, point-of-care decision-making, helping clinicians identify ischemia, infection, and tissue readiness before CTP use. These tools also support early intervention and weekly monitoring to reduce the 4-week reassessment window.

·      Evidence-based practice must incorporate clinical expertise and patient context, not rely solely on randomized controlled trials. 

·      Technology bridges clinical gaps in underserved populations, enhances documentation for payers, and improves outcomes across patient types—including those with darker skin tones, where visual assessment is limited. Infrared tools provide objective, color-independent data that improves care equity and precision.

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

Frank Aviles, Jr., PT, CWS, FACCWS, CLT-LANA, ALM, AWCC: 

My name is Frank Aviles. I'm a physical therapist that has specialized in chronic wounds for the past 35 years. Also a lymphedema therapist. I am currently working in Naples with mobile rehab and lymphatics, doing both wounds and also lymphatic work. In addition to that, I like to advocate. We do it through the Frank and Lizzie Show with Elizabeth Faust. And I'm involved with a lot of nonprofits to advocate and to make sure that patients receive what they need. 

We all know what the problems are with our chronic wounds, whether we're talking about chronic wound hypoxia, abnormal inflammation, infection, biofilm, decreased perfusion, decreased diffusion, and also maybe bacteria. But we know that all of this is happening beyond the skin or the wound surface. So, it's really hard for us to really see it unless we look at the clinical signs that we learn, but our visual assessments usually fail us a lot if you read the studies. 

And so technology with cellular tissue products, it has been changing how we practice. I've been involved with technology for the past 6 years using near-infrared spectroscopy, using infrared thermography, and anything else that's out there. And I've used a lot of different products. But what I'm going to tell you is that it can help us predict which patient can benefit from these cellular tissue products. And it may be that it can help us figure out what the optimal biological window for that product is and not use these products as a Hail Mary and try to make them fit into every patient. And so if we do that, we're not only improving outcomes, we're reducing waste and enhancing cost effectiveness. But again, we're able to pick up the right patient at the right time and the right product. And I can tell you a lot of different cases where we've done that. 

And so not only we're able to help pick the patient, but it allows us to monitor them dynamically. We talk about the 4-week marker. With technology, for the past 6 years, I just have to have them come back. And within 1 session, I can tell you if we're heading in the right direction. And that's important, because if we're using a cellular tissue product, maybe that wound needs an adjunctive modality that can help. And a lot of times we at our centers use the technology to help us guide. For example, if now we're looking at thermography, if the numbers show elevated, it could be that there's an occult infection that has not been treated. I can't tell you how many times we've seen that. And instead of waiting 4 weeks, we were able to do it on point-of-care bedside. And so the technology is there to help us along with prevention. And there's so much more about prevention beyond this conversation, but technology will definitely change how we practice. 

In 35 years, I've seen that we've gotten away from practicing what we love to defend what we have to order or what we have to do. And when it comes down to what's targeted by insurances and payers, it's definitely the DFUs, diabetic foot ulcers, and the venous leg ulcers. So, that population's going to be affected, but we're going to have to have a better documentation and expectations so we can make the clinical decisions. And I will tell you that I like to separate myself in a way. We always talk about financial and clinical. I try to separate, and I try to stay clinical and let somebody else do the financial. But nowadays, that's so hard because there's no assurance that there's going to be reimbursement. 

And I'll tell you a story. When we start looking at evidence, we selected evidence-based products and the insurance or the payer told us that we're not going to pay for it. And when questioned, they said, "It is evidence. Use it. We're just not going to reimburse you for it." And so it kind of makes us practice in a different bubble. 

And so the way we practice has changed so much over the years. We have near infrared spectroscopy that measures tissue oxygenation. A lot can be told with that. That's a ratio of oxyhemoglobin and deoxyhemoglobin levels that can give you an answer that wound should be in a progressive state. Thermography looks at whether the temperature that's emitted from the body, it's high or low. We associate low with ischemia, we associate high with infection, but also realize there's more. We're looking at the metabolic activity that's happening below the skin. And then of course, fluorescent imaging, which now we're looking at a bacterial load, and there's a lot of documentation, a lot of research showing that you can use this to target your debridements. And so we have all the technology, and with the CTPs, I'm going to tell you that we know that the vascular assessment criteria changed. So instead of doing just an ABI or anything else, now imaging can actually help you perform the vascular assessment. 

So, a lot of you know that I practice in rural America, and there's a big disparity between our friends in the bigger cities. We lack the resources in rural areas. And so we also are affected by sometimes there's a wage index, and for some reason, our wage index is far lower than the bigger cities, so it affects it. But to answer your question, smaller and rural practices may be limiting the use of cellular tissue products because of administrative or even financial risk. While hospitals, they may navigate the changes more easily, but they're going to do it more slowly, and it's going to be more stringent. And so now you're going to have a stringent approval pathway. 

So, an example I'm going to mention is that many years ago, we had a VAT committee, and I was part of it. Actually, we started this. And as time went on, everybody kept talking about evidence. And for some reason, I think there's a misunderstanding, because there's different levels of evidence, and everybody goes to the top, randomized controlled trials. And so we were trying to get a product, not to even purchase, but to trial. And the evidence-based wording came out. And so this went on for weeks, and we were trying to get this product to save somebody's leg. We tried everything, there was nothing else, and this was the last thing that we thought could help this patient. And I had to put my job on the line. And yes, I ended up having to dismiss myself from the VAT committee, because I took this to heart, because we're here to help patients. 

But this expectation that the products have to deliver all this information is wrong. But to tell you, this lady, who was the family member of one of our people on the VAT committee, actually, we saved her leg. And so we talk about evidence-based when it comes to CTPs and in smaller and rural areas, it's going to affect even more, because the definition of evidence-based is not what we think. It's not all research. 2020, Dr. Paul Sackett, what he said was, and actually regarding the date or the year, I might've gotten it wrong, but it was in the early 20s or 2000s. And Paul Sackett said, "Evidence-based medicine is the explicit and judicious use of best available research." And that's what we stopped. 

When it comes to CTPs, we stop there. Smaller companies can't get that research, but he went on to say that we also have to consider the skill and the knowledge of the clinician. 

When I went to the VAT committee, I had used products like this before, and I knew it would help. And then also it says, in addition to that, you have to take the patient in consideration. And so if we only use randomized controlled trials, we're not going to be able to help a lot of the patients. So, it will affect not only the smaller and rural areas, but also the patients that need these products. 

And so from a scientific standpoint, the expectation should be that it's more than just research. And so, like I said, smaller companies that may have the best technologies and robust data, as they're trying to grow their clinical evidence, it could be that they may be faced with limited or inconsistent coverage because we don't have that. 

And I'm going to give you an example of something else that's happening kind of parallel to the CTP issue. I'm part of the Save a Leg, Save a Life Foundation, and I've done a lot of work in saving limbs all over the country. And we had a patient that there's a lot of evidence on topical oxygen, because we all know that the wounds have chronic hypoxia, and he was facing an amputation. The reality was that they tried everything. He couldn't qualify for things he needed. And so we did fight for this patient, and there's a lot of evidence on topical oxygen. And if you look at all the data, I can recite it for you, but it's still not covered. And so we have a problem with getting the products we need to the patients out there. So, with CTPs, there's a lot of growth, there's a lot of overutilization. And I know you have to draw the line, but we just have to make sure that the tighter coverage and payment controls will not affect the population we serve, because the challenge moving forward is creating policy that distinguishes between appropriate biological use and not restricting access across the board, because that will affect my rural places that I work. 

We all talk about having a multidisciplinary team, but we are not usually able to for one reason or the other. And moving forward, that may be a mixed impact, but we need to define who's on our team. And as my opinion, I have to say a lot of times there's one person that we consider them an outsider and we should maybe include them and give them accountability. And that's having industry be part of it, because let's just say reps will come to our office and talk about products, but they need to also talk about the benefits, but they should be there telling us when not to apply it. It shouldn't be based on financial, it should be based on what's best for the patient. 

And I'm going to tell you, there's two reps out there and I want to give them credit. And one of them is Carl Bahe and the other person is Chris Klotz. They work for different parts of industry that has challenges now because of the CTPs and other things, but they consistently want to do what's right for patients. Sometimes they bring me in to meet with the doctors, because I've never seen a rep say, Frank, this doctor may not be able to use the product appropriately, and we need clinical help. And so that to me speaks volumes, because they're not there just to sell. They're there to make sure that we apply the products appropriately, not overuse them, and that the patient gets the best benefit out of it. 

And so. again, what we're trying to do is provide documentation, use utilization, and have a standard of care with what we do. And we do have technology available to help us with how to predict which patients are going to have a better outcome. And if I ever get to share some of my work, and actually I will send you some images so you can see what I'm talking about. Number one, I'm going to send you an image of a patient that everybody wanted to apply a CTP, but the infrared image was hot. It told me there was an occult infection that's not being treated. Another one had decreased oxygenation to the wound bed, and we were able to use adjunctive modalities first before we put the CTPs. We gave it the best chance. And if you look at some of our work, on the average, we were applying 2 to 3 products on most patients. 

And then also, we were able to look at debridement temperatures. One of my first posters was about, if we do effective debridement, we should see a temperature change. And the patients that didn't change, then we realized that one, maybe the debridement was not effective, or maybe we had a patient that had a chronic wound that needed something else before we apply the product. And so I guess as closing thoughts, we do have the technology that can change all of this, so we can apply whichever specific product the patient will benefit from. 

Let's review some of the images we've been talking about. I've been blessed to be able to use a lot of the technology available to us. And so I recommend, make sure that you test them all, and see which one you like best, and make sure that they're FDA approved. The images you're seeing now are from the MIMOSA Pro. This device is a great piece of technology that allows us to do 3 things. Look at near-infrared spectroscopy, which is tissue oxygenation. Now with the new changes with CTP, they want us to do also a vascular assessment that we could use imaging for. Now, imaging is not a standalone tool, and so this bedside is great way to head you in the right direction. And then the thermal image that you see on the far right measures kind of the temperature being emitted from the body. Now, of course, this is a wavelength that is not visible to the human eye, but you're able to see abnormal and normal levels of temperature, which lead to inflammation and possibly infection. With this patient, case one is a diabetic foot ulcer. We're able to use technology to tell us, is this the right time for a CTP application? And in my opinion, this one's not yet. If you look on the oxygen at the wound bed, it's 47%. This tells us that it's got decreased oxygenation to the tissue. Now, we're able to select interventions to raise that number up, and there's a lot of things that we've done to raise the temperature or the oxygenation to that wound bed. On the far right, the temperature, you'll see that the wound bed is slightly elevated than the periwound tissue. And at this point, it may not be an abnormal level, and so you can monitor this on a weekly basis. 

On the next case study is the venous leg ulcer. As you can see on the far left the tissue oxygenation, and the wound bed is 31%. That's way lower than we want to. So bedside pound of care, that tells me, are we dealing with a perfusion issue or diffusion? And so venous leg ulcers, what I found is once you clear the vascular status, it may be just diffusion. And so it may be that this patient needs compression as part of the treatment, whether we apply a CTP today or the next week. And so now you can evaluate, is this the right patient at the right time and such? 

The next slide, this is something I did recently, but I've done it with a lot of modalities. And as you can see on the left-hand side, this is tissue oximetry. The blue means a little lower than what you want, a little ischemic. And then if you look at the number in the 50s of that point that I selected, and I did a treatment to raise that oxygenation, as you can see on the picture on the right, the blue disappeared, and also we got an increase of at least 20% in oxygen to that area. And we can do that with a lot of modalities, but I will tell you, if you don't debride, debridement's huge because we've seen the right amount of debridement can help increase that oxygenation. 

Now, on the fourth slide that we see here, this is a lot of times I've seen this with lower extremity wounds, but I wanted to highlight this because this is a finger. And as you can see on the visual image, it's just swelling that we see, nothing else. But when you look at the thermal image, what I circled here, that abnormal coloration, when it comes down to it, it's significant to the point where it's close to being infected, in my opinion. And so a lot of thresholds of temperature I've seen over the years kind of lead me in a direction, but this patient needs quick attention, whether it's antibiotics, surgical approach or such, before we go anywhere else. And the reason why I wanted to bring this case is because I've seen patients in the OR that elicit the same temperature level and somebody applied a CTP, and I'm going to tell you, it didn't survive. And other patients that we address that inflammation, abnormal inflammation, and then apply a CTP, the wound has progressed like you wouldn't believe. And so this is just another way for little case studies to show you that technology can help not only select the right patient for the right time, but also evaluate if we need adjunctive modalities to make our CTP more successful. 

So, we have near-infrared spectroscopy, and we have thermography, and then we have fluorescent imaging, and a lot of these devices actually will measure the wound for you. And so as you are trying to get payer approval on some of these products, I'm going to tell you that you need better documentation, and these devices can do that for you. But not just that, you can look at it for prevention, you can look at it to monitor progress, to decrease that 4-week healing observation to now you can do it from week to week, serial images, but also you can select interventions based on the images. And so at this point, I do want to say when you look at near-infrared spectroscopy, you're looking at tissue oxygenation. I can't tell you how many times I've been able to look at an extremity and say there's ischemia, or it may be that the wound is so hypoxic that we need another modality before we can apply that cellular tissue product.

When it came to thermography, there's a lot of times where you have a different temperature, whether it's hypo- or hyperperfused, but that always leads to something abnormal. And it's not just about perfusion, it's looking at metabolically what's happened there. Maybe the cells are having more energy to fight something. And so the combination of 2 in the past 6 years have led me to a lot of findings, but consider the patients with darker pigmented skin. We miss a lot on our visual assessment. Technology doesn't look at color. And so I believe there's a lot of information out there on technology, especially infrared, but what I'm going to tell you is look at the thermometer. If you look, there's no double randomized control studies out there, but we use a thermometer at home to determine if we have to go to the doctor, if there's a problem. Or better yet, actually, I used this at a talk the other day; we have a tornado watch and tornado warning. And when it comes to technology, at watches, you may have a tornado maybe developing in your area, but it doesn't say take cover. A tornado warning says it's heading in your direction. It may or may not happen, but just be prepared. 

So, the way I look at technology is let's be prepared. If we see something, we know that infrared may not stand alone, but we can guide a point of care, or we can make decisions right away, and the patient does not have to wait 3 weeks to get their assessments and all that in the meantime. And so technology will definitely impact the way we select cellular tissue products.

Frank Aviles, Jr., PT, CWS, FACCWS, CLT-LANA, ALM, AWCC, is a physical therapist and certified wound specialist with more than 35 years of experience in chronic wound care and lymphedema management. He practices with Mobile Rehab and Lymphatics in Naples, Florida, and is an active advocate for patient access, limb preservation, and evidence-informed wound care innovation.